A common area of weakness among undergraduate athletic training programs is education on recognizing and referring psychological disorders. Recently, it does seem there’s an increase in the number of sport psychologists employed at the Division 1 setting, but due to budget reasons it is highly unlikely high schools, Division 2, and Division 3 schools will have ease of access to sport psychologists on campus. This leads the athletic trainer to be the closest person in contact with athletes on a daily basis. It is helpful for athletic trainers to know common psychological disorders and their signs and symptoms for proper referral. An athletic trainer should not take on the role of head psychologist, but be able to lead an individual in the right direction for treatment.

Anxiety Disorders:

Anxiety disorders typically include feelings of dread, fear, or worry and include panic attacks, social anxiety, obsessive-compulsive disorders, PTSD, and generalized anxiety disorder.

In the last two years working at a Division 1 school, I have encountered multiple panic attacks, social anxiety disorders, and generalized anxiety. Panic attacks have typically happened post very stressful physical tests. Signs and symptoms included rapid heart rate, hyperventilation, sweating, nausea, and light headedness, which in some cases lead to fainting. In all of these cases, I was aware the individual also had generalized anxiety disorder. The main focus should be in calming down the breathing rate to avoid more serious issues such as shock. Breathing into a paper bag or having the individual breath in through their nose and out their mouth are two ways to slow down the breathing rate. Typically it has taken between 5-10 minutes for individuals I have encountered to calm down, but each person has a range of response during a panic attack.

Social anxiety disorder seems to be a common place in the athletic world. It often includes a fear of performance or social situations. Fear of failure or embarrassment is a common symptom. This is seen before an individual test that may determine where the athlete is placed on the team, before a big event in front of many fans, or could occur after several disappointing performances leading to increased social anxiety in the future. Coping mechanisms and talking through the stressors could help ease this anxiety.

Most people have probably experienced some form of generalized anxiety disorder in their lifetime. Common symptoms include excessive worry, disturbed sleep, increased irritability, problems focusing, increased fatigue and muscle tension. This is a concern since many of these symptoms leading to an increased chance of injury. Coping mechanisms and treatments that may help include relaxation, imagery, massage therapy, heat modalities,and stretching. I have found by chatting with individuals during their treatment time about anxiety issues they have, then re-focusing their attention on positive things in their lives, helps maintain adherence to a rehab program and decrease anxiety signs/symptoms.

Mood Disorders:

Mood disorders include depression, bipolar disorder, dysthymic disorder, and cylothymia. The most common mental health issue I have come across is depression, but have had several individuals with bipolar disorder too.

Men have a 5-12% chance and women have a 10-25% chance of experiencing depression at some time in their life (Andersen & Kolt, 2004). Signs and symptoms include sadness, hopelessness, loss of interest, disordered eating, disordered sleep patterns, weight fluctuations, fatigue, increased agitation, suicidal thoughts, and difficulty concentrating. Managing depression is important in the athletic training setting. If an individual is depressed it can lead to decreased adherence to rehab programs, increased risk of injury due to fatigue and stress, and loss of interest in return to sport. Seeking therapy or consulting with a physician when these signs and symptoms are present is key. A helpful survey used at the University of Minnesota athletic department is the patient health questionnaire (PHQ 9). This survey is self reported by the individual and helps detect signs of major depressive disorder.

Eating Disorders:

Unfortunately, eating disorders are prevalent in the sports world. Many times, this disorder increases with sports that have higher focus on body image; gymnastics, track & cross country, swimming and diving, volleyball for both men and women to name a few with higher incidences. Eating disorders are harder to detect since most people know it’s wrong and hide it very well.

The average age range for athletes whom Athletic Trainers work with are between 15-24 years. This age group is at a high-risk level for suicide (Milliner & Smith, 1994) There are many common signs and symptoms health care professionals should be aware of to properly refer athletes who are at risk of harming themselves.

It is important for health care professionals to be aware of these risk factors when working with an injured athlete. The following are some Do’s and Don’ts regarding suicide:

Do’s:

Take signs and symptoms of suicide seriously

Always stay calm if a crisis arises

Be a good listener. A short venting session during rehabilitation gives a lot of insight on thoughts, feelings, and emotional stability; giving more support if a referral is needed

Empathize with pain the individual is feeling

Ask direct questions i.e. Do you intend to harm yourself today? Do you have the means to harm yourself?

Identify the stressors in the individuals life and provide coping mechanisms or support to help get through the stress

Ask about their support system; friends, family, coaches etc.

If at any moment there is suspicion that the individual will carry out their plan before intervention, contact emergency services by calling 911.

If the crisis is not emergent, the Twin Cities area has a 24 hour crisis hotline that will talk to the individual through issues:

612-379-6363/1-866-379-6363

There is also a National Suicide Prevention Hotline:

1-800-273-TALK (8255)

Don’ts:

Do not assume the individual will not follow through with a suicidal plan

Stay calm; do not debate or argue with the individual

Do not minimize their feelings

Do not assume that if they attempt once they won’t attempt again

Don’t be afraid to ask (use the bullet point statements regarding ideation)

Don’t try to handle the issue alone. Seek support from other health care professionals such as doctors, sport psychologists, and administrators

It is always better to play on the side of caution when dealing with a possible suicide case. Refer to a sport psychologist or mental health institution when risk factors are identified. Be sure to stay in contact with the individual, providing support, and letting them know they are cared for.

As an Athletic Trainer, it’s important to get input from certified sport psychologist’s regarding their thoughts on athletic trainer’s involvement with athletes. Athletic trainer’s find themselves heavily involved with psychological issues on a daily basis.

Dr. Justin Anderson Psy. D, LP. is a licensed psychologist who practices through his own company who he run’s with his wife Dr. Carlin Anderson Ph.D., LP, CC-AAS at Premier Sport Psychology and also provides the University of Minnesota athletic department with comprehensive sport psychology services. He works with athletic trainers and athletes on a daily basis.

Since you’ve been employed at the University of Minnesota, how has your relationship with athletic trainers helped or hurt your practice?

I believe it has definitely helped. The ATC’s are typically the closest to the athletes and tend to have a good grasp of how athletes are doing from a health and wellness standpoint. Therefore, the athletic trainers who are well versed and understand how psychology can benefit their athletes are providing us with the most referrals. We get a majority of referrals from athletic trainers (over academic counselors, coaches, administration, or faculty).

Athletic trainers tend to be well trusted by an athlete, so if they’re making a recommendation to see a sport psychologist, most will take the next step in getting support they need to become a better athlete and healthier person.Do you feel there is a greater need for sport psychology courses/education for athletic trainers?

Do you feel there’s a greater need for sport psychology training in an athletic trainer’s education?

Yeah, I think athletic trainers will continue seeing a lot of mental health issues, so being able to identify symptoms early and make proper referrals to sport psychologists can help reduce a possible crisis issue down the road. It takes education to recognize those symptoms and understand the benefits of psychological interventions.

What advice could you give to a recently certified athletic trainer on handling mental health issues?

Be able to spot and identify the big mental health issues (significant depression and anxiety)

Off the field issues can greatly impact performance on the field… so learn how to casually check in with athletes and see how they are doing from a holistic perspective

Learn how to normalize the mental health/well-being mental side of training. Understand how best to make referrals without adding stigma to it. Refer to sport psychology as a “no brainer” (i.e., it is now just part of the athlete development process- why wouldn’t an athlete want to improve health and performance?)

Understand sport psychology professionals can work on the spectrum of issues from clinical mental health issues, to improving one’s mental side of performance

Refer more athletes who are doing well to sport psychologist to continue to improve. We don’t always want it about deficiencies in performance or well-being.

Maybe in some cases one can become too involved, but in general we haven’t seen too much evidence of athletic trainers being too enmeshed with athletes. The athletic trainers we’ve worked with at the U of M have had a great level of professionalism, which keeps the boundaries in a healthy place.

What’s your opinion on athletic trainer’s ability to maintain their own mental health? What are some coping mechanisms you could suggest if someone is having a hard time?

Being an athletic trainer can be physically and emotionally draining. Be sure to get plenty of energy for the body (physically – e.g., Good rest, diet, exercise, etc) and mind (emotionally- e.g., find some balance or take time away from work/sport, ability to take quick/short relaxation breaks during the day/moment, and seek fuel from others (athletic trainers spend a great deal of time taking care of others, so it is essential to
find a support network that will check in every so often. If needed, come see a sport psychologist and we can give few more tips to optimize your thinking and overall well-being!)

Dr. Justin Anderson Premier Sport Psychology

Thank you Dr. Anderson for taking the time to answer these important questions.

Mindfulness provides the foundation for Dialectical Behavioral Therapy (Linehan, 1993) and could be an effective way for injured athletes to cope with distressing thoughts and emotions surrounding the sport-related injury. The basic premise behind mindfulness is to help individuals learn how to pay attention, in a non-judgmental way, to the present moment. Just like muscles that need to be conditioned on a regular basis to get the most out of them, skills related to self-regulation need to be worked out on a regular basis to experience the benefits of them. Mindfulness activities provide users with skills that can be practiced on a regular basis in a relatively short amount of time to help better regulate distressful thoughts and emotions. The following activity is an example of a mindfulness activity and could potential aid in your recovery from a sport-related injury.

Thoughts are just that – thoughts. A lot of time they have no meaning and often are not based in reality. This activity helps individuals realize that thoughts come and go and that they do not necessarily need to control you emotions and behavior. Close your eyes and pay attention to your breathing. As thoughts come into your head, imagine that you place them on clouds passing by as you lay in an open field or on leaves passing by as you sit by a running river. Place each thought on the clouds in the sky or on the leaves in the river passing by. Let go of these thoughts and watch as they quickly pass with the wind in the sky or the current of the river.

Practice this technique on a regular basis and you will be amazed at how efficient you become in regulating your thoughts, emotions, and behaviors. Let go of those maladaptive thoughts surrounding your injury.

In an evaluation of the various components of the integrated model of psychological response to sport injury (Wiese-Bjornstal et al., 1998), Wiese-Bjornstal and colleagues (in press, 2012) found that individuals with a higher level of athletic scholarship (i.e., full vs. partial vs. none) were more likely to experience a sport-related injury. The authors suggest that the finding needs to be explored in future research to better understand the factors that affect athletes differently based on level of athletic scholarship. However, we want to hear your opinion to help guide our research of this interesting finding and, possibly, to help in the development of a measure that can better assess stress associated with athletic scholarship status. Based on your own experience, another individual’s experience, or a general hypothesis, what factors associated with an athletic scholarship could increase the risk for an athlete incurring a sport-related injury?

See how professional distance runner, Delilah DiCrescenzo (“Hey There Delilah“), makes use of a strong social support system to deal with an injury that ended her season prematurely, forcing her to withdrawal from the 2011 Track & Field World Championships.

We want to hear your story. What role has social support played in your recovery from a sport-related injury? What was helpful when interacting with significant others during your recovery process? What do you wish people would have done differently?

Sport-related injuries are an unfortunate consequence of engaging in sport and recreational activities. Although a variety of physical and psychological factors influence the risk for sport-related injuries, one specific component or facet of sport-related injuries that has received attention in the literature, particularly in youth sports, is injuries that result from illegal behavior or illegal contact on a sport field (Collins et al., 2008; Arthur-Banning et al., 2009; Fields et al., 2010). Despite this attention in the literature, sport injury prevention efforts related to illegal behavior are lacking. Therefore, a proposal is made to implement a school-based violence prevention program (Prothrow-Stith, 1987) as a way to directly reduce youth violence in general as well as youth sport violence and, as a result, possibly indirectly reduce the risk of sport-related injuries.

The Violence Prevention Curriculum for Adolescents (VPCA; Prothrow-Stith, 1987) was created to address violence prevention in middle and high schools by teaching individuals that violence is preventable, informing youth and adolescents that anger is a normal part of life and that it can be expressed in healthy ways, instilling that controlling anger is a part of maturing as an individual, inculcating that there are positive, healthy, and pro-social ways to express anger, and outlining alternatives to violence through specific conflict resolution techniques. The VPCA curriculum involves 10, 50-minute classroom sessions that provide teacher-led didactic instructions, group discussions, small group activities, role playing of various conflict resolution scenarios, and multi-media presentations.

Given the lack of sport-specific prevention programs, particularly prevention programs that address illegal behavior on a sporting field, would a school-based violence prevention program be an effective way to address this problem in youth sports and, ultimately, address sport-related injuries? What are potential limitations of implementing a school-based violence prevention program with hopes of reducing both youth violence and illegal sport-related behavior?